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Showing results for "happened".

1541. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable Citation Text: Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

1542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49625/psn-pdf
      May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…

1543. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
      May 01, 2014 - PowerPoint Presentation Spotlight Medication Reconciliation With a Twist (or Dare We Say, a Patch?) This presentation is based on the May 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…

1544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33646/psn-pdf
      February 01, 2007 - In Conversation with...Joseph Britto, MD February 1, 2007 In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical decision support syste…

1545. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
      February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…

1546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

1547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72693/psn-pdf
      January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…

1548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50842/psn-pdf
      January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…

1549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860049/psn-pdf
      January 04, 2024 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. January 4, 2024 Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient The Case A 9…

1550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49476/psn-pdf
      March 02, 2005 - Around the Block March 1, 2005 Minichiello T. Around the Block. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/around-block The Case A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee replacement. The orthopedic surgeon, recognizing the risk of deep vein th…

1551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

1552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49493/psn-pdf
      November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…

1553. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
      December 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case December 2006 Hidden Heparins: HIT Happens Source and Credits This presentation is based on the December 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrick F. Fogarty,…

1554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49472/psn-pdf
      March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…

1555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851158/psn-pdf
      June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …

1556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33685/psn-pdf
      May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA May 1, 2009 In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and Family M…

1557. Saved by ECMO | PSNet
      psnet.ahrq.gov/web-mm/saved-ecmo
      May 05, 2017 - Saved by ECMO Citation Text: Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

1558. Building a Safety Program Using Principles of Resilience Engineering | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
      October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Citation Text: Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…

1559. The Wrongful Resuscitation | PSNet
      psnet.ahrq.gov/web-mm/wrongful-resuscitation
      October 12, 2012 - The Wrongful Resuscitation Citation Text: Teno JM. The Wrongful Resuscitation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

1560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837958/psn-pdf
      December 01, 2021 - EMS Perils from Hospital Overcrowding August 31, 2022 Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding The Case A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…